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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619246
Report Date: 08/13/2021
Date Signed: 08/13/2021 09:49:35 AM

Document Has Been Signed on 08/13/2021 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:SCRIVNER, ELIZABETHFACILITY NUMBER:
343619246
ADMINISTRATOR:SCRIVNER, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 745-3415
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/13/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Elizabeth ScrivnerTIME COMPLETED:
09:55 AM
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On 08/13/2021 at 8:48 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller met with Licensee, Elizabeth Scrivner for the purpose of an unannounced annual inspection. The census was four day care children in care. The Licensee's child and husband were present. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted in all areas accessible to children. The off-limits areas of the home are: master bedroom/bathroom, garage, and side yard. LPA observed the required postings, a working phone, 2-A-10-BC fire extinguisher, and functioning smoke and carbon monoxide detector. Licensee stated there are weapons in the home and LPA observed they are inaccessible. The facility has a pool and spa inaccessible behind a fence that meets Title 22 regulations. Toxic and hazardous items are inaccessible to children.

LPA reviewed four children's files and observed that each child has their emergency contact information. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. The Licensee's Pediatric CPR and First Aid expires 02/2022. The Licensee's Mandated Reporter certificate is current and expires 02/2022. The website for the Mandated Reporter Training is mandatedreporterca.com .

This provider is currently not providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Report continues on 809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: SCRIVNER, ELIZABETH
FACILITY NUMBER: 343619246
VISIT DATE: 08/13/2021
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LPA verified the annual fees are current. This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

At this time no deficiencies were cited. An exit interview was conducted. Notice of Site Visit was given and posted.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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